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Case study for non-medical prescribing
This case study aims to demonstrate the safety assessment of a patient, formulating a diagnosis, deciding on treatment, and planning his care. Moreover at the heart of it is to demonstrate the ability for safe prescribing and evaluation of patients as an NMP. Throughout this piece, the ten RPS competencies are taken into consideration and a selected Consultation model is used to provide an assessment structure, this had to be straightforward, practical, and provide guidance to meet the patients and my needs. It is this that enables advanced nurses to a new medicalized role (Beaumont, 2012).
Non-medical prescribing was initially discussed in 1986 as a way of making improvements to delivering care, from a limited list of items agreed upon by the DHSS. The DOH went on to publish a report outlining recommendations for nurse prescribing (Crown Report, DOH,1989). Its’ intention was that this would lead to improved patient care, improved use of both nurses’ and patients’ time, and improved communication between team members because of the clarification of professional responsibilities. (DOH 1989). Training for non-medical prescribing did not start until 2002 and has now been expanded to include other professionals.
In my practice as an Uro- Oncology Clinical Nurse Specialist in the Secondary Health care setting the need for a more autonomous ability to practice and gain the qualification to prescribe independently is encouraged and supported. It is hoped this works toward building a flexible and dynamic workforce (Van Ruth et al,2008). I have worked in the field of Urology for my entire career and welcome a further qualification to enhance my practice. One study highlighted nurses felt that there were concerns about the effects on the role of the nurse blurring the boundaries between nursing and medicine Latter et al (2005) Another study demonstrates the benefits to be able to deliver complete care episodes, improve a multi-professional working, ease of access to medicines and improved patient information about medicines (Avery et al.,2004)
To become an independent prescriber, The Royal Pharmaceutical Society produced a framework in 2016 outlining the knowledge, skills, characteristics, qualities, and behaviors required for safe and effective practice by all prescribers. The tool has been promoted as effective for most but daunting to others. kat hall, Cathy Picton 2020. It lays out the need for improvement. There are ten competencies divided into two groups and I will be exploring these throughout this study.
My role involves running nurse-led clinics and assessing patients independently, formulating a treatment plan, and reviewing appropriately. The first RPS competency is assessing the patient. The patient chosen for this study is a 65yr old man who presented to the Urology department with an elevated PSA and he had undergone a prostate biopsy to rule out cancer. The histology concluded he was suffering from Benign prostatic hypertrophy and he attended my clinic for his results. He will be referred to as Mr. X to maintain confidentiality and protect his identity ( HCPC 2017). To establish a rapport and gather the information, I discussed the initial presenting complaint of elevated PSA and explained the histology findings from his biopsies, he was naturally relieved not to have Cancer. He complained of lower urinary tract symptoms (LUTs) including poor flow, nocturia x 3, incomplete emptying, and daytime frequency. LUTs symptoms occur in up to 30% of men ages over 65yrs (Abrams P 1994). He completed an International prostate symptom score questionnaire to give a clear outline of his symptoms and aid with the management plan. In 2012 LUTs in men were the subject of a NICE quality standard and his assessment included all the recommended investigations (NICE quality standard 45) Mr. X had completed a standard questionnaire which is a patient-reported outcome measure, the International Prostate Symtom Score( IPSS), assessment of his symptoms from his perspective (Barry et al,1992) It is a valid and reliable tool and is widely used (Lujan Galan et al .,1997) Digital rectal examination (DRE) had previously been done and a frequency volume chart, which is extremely useful in the assessment of men with bothersome LUTs (NICE guideline 97).
To carry out a full assessment and get an accurate medical, social, and medication history including drug allergies I chose to use the Calgary-Cambridge model (Kurtz et. al,2003). Prescribers are encouraged to do a consultation in a structured way (national prescribing center, 2003). The model has five steps covering both disease and illness frameworks. It is both comprehensive and evidence-based. The disadvantage of this model is that there are seventy-one micro skills not all of which are required for each assessment. It helps to build the relationship with the patient using the appropriate skills for the individual. Mr. X was greeted and my role was explained. Open questions were used to establish a rapport and gain his understanding of his bothersome symptoms, listening without interruption. The information was gathered and summarization was used to ensure he understood and that I understood his perspective. His LUTs had been ongoing for twelve months and had got worse since his biopsy. He had no past medical history other than an appendicectomy as a child and was not on any medication. He was fit and well with a keen interest in walking, doing 2 miles every day to maintain his health. There were no known drug allergies. He was married with a daughter, retired as an engineer, and had no family history of ill health.
I chose not to use other models such as McWhinney’s Disease-Illness model (1986) as whilst being a simple model it focuses on the clinicians’ agenda and is often referred to as the ‘disease Framework’.I felt a more integrative holistic approach was needed knowing he had concerns about cancer and I wanted to address some lifestyle intervention for his symptoms. Lifestyle interventions are extremely influential with LUTs, nicotine, and Caffeine universally reported as the two most significant bladder irritants (Arya et al 2000). All men undergoing assessment are advised to eliminate both to improve symptoms. Other beneficial lifestyle modifications are weight loss, pelvic floor exercises, fluid manipulation, and avoidance of certain foods and drinks (Lohsiriwat et al 2011) Mr. X was consuming large quantities of Caffeine during the day and we discussed how changing to de caffeinated Tea and Coffee would contribute to improving his symptoms.
The medical management available to him was explained, and by this point, we had established a good rapport and he was keen to explore all the available options open to him. The Calgary ‘Cambridge model (2000) is useful in achieving concordance as its focus is on building a relationship with the patient and maintaining a patient-focused discussion. Pharmacological management, of Benign prostatic hypertrophy causing obstructive symptoms, comprises two classes of medication-alpha blockers (e.g. Tamsulosin, Alfuzosin) and 5-alpha reductase inhibitors(5-ARI) (e.g. Dutasteride, finasteride). The pharmacokinetics of the two drug classes differ vastly: alpha-blockers have a rapid onset of action (24-48hrs), while the 5-ARIs take 3-6 months to reach peak effectiveness (Nazlund et al 2007). The NICE quality statement 6 states that men with LUTs receiving alpha-blockers should have their medication reviewed after 4-6 weeks (Nice website 2014). This consultation has been written from the perspective of a prescriber, the Consultation was done in the presence of a qualified prescriber who issued the prescription as per requirements by HCPC prescribing standards (reviewed 2021).
Moving the Consultation to the explaining and planning phase and working towards a shared decision we reviewed together all of the results and assessment documents it was clear that Mr. X had poor flow, a significant residual volume of 200mls, and severe bothersome symptoms with an IPSS score of 20 (Barry et al.,1995). Following discussion and looking at the information, he was provided we decided, as per NICE guidelines, to commence him on Tamsulosin 200mgs daily. This drug cannot be prescribed in people with severe hepatic impairment, a history of postural hypotension, history of micturition syncope. Caution has to be taken in prescribing it to people with severe renal impairment (eg GFR less than 30mlminute1.73m2). After cataract surgery, there is a risk of intra-operative floppy iris syndrome. In elderly people, vasodilatory effects may cause a rapid reduction in blood pressure and lead to fainting. Mr. X was advised to take the first dose at bedtime and to lie down if he experienced dizziness, fatigue, or sweating until they abate completely. He was also warned of the risk of retrograde ejaculation and erectile dysfunction.
In prescribing this drug the NMP holding the prescription qualification must prescribe in line with the requirements of the NMC code and their scope of practice. Prescribing must be in line with the relevant legislation, policies, and standards that underpin the code 9nmc section 18.1) The NMC adopted the ‘Royal Pharmaceutical Society Competency for all prescribers as standards of Competency for prescribing practice. It lays out all the steps for safe practice, all prescribers must take individual responsibility for their prescribing decisions.
Prescribing safely, appropriately, and cost-effectively is part of the treatment planning, taking into consideration the influences on prescribing practice along with the roles of and relationships of others involved in supplying and administering medication. The RPS’s Competency framework ensures a standard and benchmark of quality for prescribing and ensures that prescribing safety is maintained. It encompasses Professional accountability, advice about medicines, and ongoing management of patients using medication (RPS 2016).
Drugs have to be licensed through the Medicines and Healthcare Products Regulatory Agency (MHRA) or European Medicines Evaluation Agency (EMEA) to be used in the UK. In the NHS new drugs have to have approval by National Institute for Health and Care Excellence (NICE). These organizations look at the evidence of how effective a drug is, its limitations and drawbacks, and cost-effectiveness. When prescribing the hospital will have gone through the process and decided which drugs are the most clinically effective, safe, and cost-effective for patients. Tamsulosin is a selective alpha 1A and alpha 1B adrenoreceptor antagonist. Antagonism of these receptors leads to the relaxation of smooth muscle in the prostate and detrusor muscle in the bladder allowing for better urinary flow. It is a cost-effective treatment with a 73% reduction in the need for surgery. (online ref) Other alpha 1 adrenoreceptor antagonists developed in the 1980s were less selective and more likely to act on the smooth muscle of blood vessels, resulting in hypotension (Chappel et al 1996). Tamsulosin is on the hospital formulary and the first-line drug of choice as per local guidelines.
Nonmedical prescribing in the team context is required for it to work effectively. There is an ever-increasing demand for the Urology service requiring innovative development of roles leading to a more accessible service(Kean et al 1971) This has been acknowledged that across the NHS there is a need for streamlined, accessible, and flexible services (Department of health (DoH) 2000) and demands for practitioners to use their skills and knowledge to extend their roles beyond traditional boundaries and achieve their full potential (DoH 2001:2002). Each Trust has a non-medical prescribing lead who provides professional leadership and a coordinated approach to the maintenance and development of the NMP role (South Tees Hospitals NHS Trust 2008).GPs have restrictions on their formularies and only prescribe what is agreed upon by their Clinical Commission group. In issuing a prescription for Mr. X it must be a recognized and approved drug that his GP would be able to continue providing prescriptions for. The wider team involved in his prescription must be considered and involved. I reassured Mr. X that a letter summarising his Consultation including the plan would be sent to his GP to enable him to issue repeat prescriptions. Effective communication across the multidisciplinary team is of paramount importance to give clear and concise information on the assessment, treatment, and plan to prevent errors (Nadeem et al 2001).
The RPS competencies require the NMP to prescribe safely, professionally, and as part of a team. With the ever-rising demands on the NHS, non-medical prescribing remains under scrutiny.it is a requisite as an NMP to maintain a date with regulations and guidelines determined by the professional bodies. This incorporates education, and the legal frameworks for prescribing, supplying, and administration of medicines. The prescribing training courses have evolved and changed as it was thought they were not adequate in addressing diagnostic skills (Avery and Pringle 2005). Litigation costs have soared through the 1990s (Tingle 2002) highlighting my need for awareness of the legal process and the need for safe and effective practice. In considering the ability to work effectively in the legislative framework relative to practice the NMP can be seen to be linked with employer contact law being sure to work within the NMC and RPS standards of practice, professional accountability adhering to the NMC code of practice, Public accountability with the potential of Criminal law and patient accountability relating to potential Civil law. The Care Quality commission ensures the expected standards of care are maintained (Health and Social Care Act (2008) (regulated Activities) regulation 2014) Standard of conduct is set by my professional body, the NMC, Codes of conduct act as a principal set of rules and standards and provide a regulatory framework for prescribers.
The Consultation with Mr. X was drawn to a close with a plan to have him reviewed in the Prostate assessment clinic in three months. He was provided written information about his condition and treatment and contact numbers should he have any problems once starting the medication. Sometimes it is difficult to close a session down with patients feel nurses have more time than doctors (Silvermann et al 1998). Mr. X was satisfied with the outcome and left with a review plan and safety net in place.
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